Central paresis. Central nervous system paralysis Central paralysis is not a symptom

Paralysis in medicine is called complete loss muscle groups from motor activity. There are two types: spastic (central) and (peripheral) paralysis.

Foci of neuronal damage may be located in the cerebral cortex or in thoracic region spinal cord, defeat of the first leads to spastic paralysis, in the second flaccid paralysis appears.

Features of the violation

U healthy person When the skin comes into contact with irritants, impulses are transmitted through the spinal cord to the brain using nerve fibers. With spastic paralysis, the muscles are in constant motion. Tendon reflexes do not occur. The pain impulse does not reach the brain, creating muscle spasms and uncontrolled movements.

With spastic paralysis, the patient cannot take certain positions. cause moral suffering.

A temporary decrease in tone is possible through warming up, special massage and physical therapy.

Impulses that increase tone are internal and external in nature. Over time, the patient will learn to identify them independently character. Thus, in people with spastic paralysis the only way feel pain and discomfort becomes a degree.

People with moderate levels of spasticity may be able to walk at slow paces or transfer from one place to another.

Because central paralysis is a consequence of damage to a specific focus of the neurological system, then it may not be the only manifestation of this condition.

Characteristic consequences are impaired coordination of movement and difficulty in eating. There may also be difficulties in respiratory system and digestive problems.

Tactile sensitivity may become worse or, conversely, dull. Possible vision impairment. Caring for such patients requires careful handling. Changing your body posture can be quite difficult.

Difference from peripheral paralysis

Infantile central palsy

In development infantile paralysis The mother's lifestyle plays a huge role. Women of childbearing age should absolutely not smoke, use drugs or indulge in alcoholic beverages.

Central paralysis is a dysfunction of a muscle or limb caused by damage to the central motor neuron. This type of paralysis is also called “spastic”, as it occurs against the background of muscle hypertension.

Most often it manifests itself as damage to the extremities. The peculiarity of the course of the condition is the increase in tendon reflexes, muscle tone, and the occurrence of abnormal muscle contractions (syncinesia).

Signs of central paralysis may vary and depend on the extent of damage to the pyramidal tract nerve structures. In unfavorable scenarios, loss of function of the upper or lower limb occurs, which is located on the other side in relation to the affected area of ​​the brain.

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Symptoms vary due to the fact that damage to pyramidal fibers can occur in the medulla oblongata, on the pons, and on the cerebral peduncles. They can affect a single limb or half of the body.

Causes

It is important to understand the difference between paralysis and paresis. A sign of paralysis is when a person loses control over parts of their body. With paresis, muscles and reflexes noticeably weaken, but do not disappear. In both the first and second cases, the disorders are caused by damage to the nervous system.

Revealed whole line factors that can negatively affect the state of motor centers and central pathways to their departments, which causes central paralysis.

These include:

• traumatic lesions;
• infections;
• metabolic disorders caused by various reasons;
• genetic predisposition;
• congenital disorders;
• poisoning;
• tumors;
• poor nutrition.

People over 45 years of age are more susceptible to central paralysis, but this age is gradually decreasing. In more than half of the cases (60%), the development of these disorders was preceded by a stroke.

Disturbances in the blood supply to the brain can also cause neuronal damage. This may occur due to bleeding or due to a blood clot blocking the blood flow. In children the main causative factor is hereditary predisposition, and the pathology itself is observed at an early age.

Symptoms

Central paralysis (spastic) has a number of specific symptoms, so diagnosing it is not difficult.

The main features include:

• muscle hypertension;
• increase in the area of ​​distribution of reflexes;
• increased reflexes;
• upward wrinkling of the forehead;
• rapid rhythmic contractions of the muscles of the kneecaps and feet.

The condition is accompanied by abnormal muscle tension. When palpated, the density of the muscles is felt, which is combined with their increased resistance, both during passive movement and when exerting influence.

Significant muscle hypertension is accompanied by restrictions on passive movements in the joint - the patient cannot bend or straighten the limb, and it simply freezes in an unnatural position.

The increase in the range of reflexes causes various visible signs of paralysis. Muscle contractions (clonuses) are the body's response to tendon stretching and are the result of an increase in tendon reflexes. Rapid dorsiflexion causes clonus of the feet, and contractions of the patella muscles occur due to a sharp downward abduction of the lower limb.

Carpal foot reflexes, which arise due to disruption of the nervous system, indicate damage to the pyramidal system.

This condition is also characterized by the formation of protective reflexes, which are manifested by twitching of the affected limb after mechanical or temperature exposure.

Against the background of central paralysis, synkinesis develops. Synkinesis are involuntary movements that occur during active directed actions. May be observed different kinds synkinesis. One of the most common is intense arm movements that accompany walking.

Muscle spasticity, which occurs due to an increase in reflex tone, spreads unevenly. As a rule, half the body is immediately paralyzed. This condition is characterized by a position in which the upper limb is close to the body, the fingers and hand are bent, the foot is turned inward, and the lower limb is extended at both the hip and knee joints.

This position is most common in patients with total loss control of limb movements and is called the “Wernicke-Mann posture”. People with this diagnosis can be identified by their characteristic gait: they need to move the affected lower limb far away so that it does not catch the ground. With spastic paralysis of the facial nerve, numbness of the tongue, palate, facial tics, and nystagmus (uncontrolled eye movements) occurs.

Another difference between spastic paralysis is a decrease or complete loss of abdominal, cremasteric, and plantar reflexes.

• the patient is in an unnatural position;
• paresis of facial muscles;
• phonotoric disorders;
• speech disorders;
• clonus;
• muscle tremors;
• gait disturbances;
• uncontrolled mouth opening;
• blepharospasm (closing of the eyelids);
• uncontrollable shrugging of shoulders;
• uncontrolled flexion and extension of joints;
• muscle hypertonicity upon palpation.

Such specific symptoms allows you to quickly carry out a differential diagnosis, determining the differences between the spastic form of paralysis and the peripheral one, as well as identifying the main area of ​​nerve damage.

Central paralysis in children

Not only adults, but also children experience damage to the central nervous system. Central paralysis in children is associated with brain damage during the prenatal period and at the time of birth. When placental blood flow is disrupted, nutritional disorders and oxygen starvation. It is the combination of this reason with birth trauma and leads to .

There are other reasons: intrauterine infections, certain medications that a woman may take, hemolytic disease- all this can cause infantile central paralysis. There is increasing evidence that the hereditary factor also plays an important role.

According to statistics, per 1000 births there are 2-3 cases of birth of children with cerebral palsy. The pathology manifests itself as disorders affecting various functions: motor, speech, mental. Any violations can vary greatly in strength and can be either minimally expressed or very severe.

At severe forms A child with cerebral palsy cannot move independently or care for himself. If pathology is observed medium degree heaviness, the child’s gait is uncertain and the use of assistive devices is often required. At mild degree movement disorders may be practically unnoticeable, but the movements are slow and awkward, characteristically acceptance pathological postures, fine motor skills disorders.

Diagnostics

A neurologist examines, palpates muscles and collects anamnesis.

There are several tests that can determine the extent of damage to a limb.

Treatment

Since paralysis is not the root cause, but a consequence, efforts must be made to treat the underlying disease that caused it. Treatment of paralysis is aimed at eliminating its individual symptoms.

Paresis is a decrease in muscle strength caused by injury nerve pathways connecting the brain to a muscle or group of muscles. This symptom occurs as a result of the same reasons as paralysis.

Paresis does not have one clear cause. It can occur with any type of damage to the brain, spinal cord, or peripheral nerves. Depending on the level of damage, there are central(at the level of the brain and spinal cord) and peripheral (at the level of peripheral nerves) paresis.

Central paresis

Central paresis occurs when the brain or spinal cord is damaged. Disorders develop below the site of injury and usually affect the right or left half of the body (this condition is called hemiparesis). Most often, such a picture can be observed in a patient.

Sometimes central paresis causes disturbances in both arms or both legs ( paraparesis), and in most severe cases– in all 4 limbs ( tetraparesis).

Main causes of central paresis:

• stroke;
• traumatic brain injuries, spinal cord injuries;
• encephalitis;
• tumors of the brain and spinal cord;
• osteochondrosis, intervertebral hernia;
• cerebral circulatory insufficiency due to atherosclerosis, arterial hypertension or other causes;
• amyotrophic lateral sclerosis;
• cerebral palsy (CP).

With central paresis, the decrease in muscle strength is expressed to varying degrees. In some cases it manifests itself as fatigue and awkwardness, while in others there is an almost complete loss of movement.

With central paresis, the part of the spinal cord below the site of injury remains intact - it tries to compensate for the disturbance. This leads to an increase in the tone of the affected muscles, strengthening of normal reflexes and the appearance of new, pathological ones, which do not occur in a healthy person. Thus, in a patient who has suffered a stroke, the tone of the forearm flexor muscles increases. Therefore, the arm is always bent at the elbow. On the leg, on the contrary, the tone of the extensors increases - due to this, it bends at the knee worse. Neurologists even have a figurative expression: “the hand asks, but the foot mows.”

Due to increased muscle tone and impaired movement, central paresis can lead to contractures (restriction of movement in the joints).

Peripheral paresis

Peripheral paresis occurs when the nerve is directly damaged. In this case, disorders develop in one group of muscles that this nerve innervates. For example, muscle weakness may be present in only one arm or leg (monoparesis). The larger the nerve is damaged, the larger part of the body the paresis covers.

The main causes of peripheral paresis:

• degenerative diseases of the spine, radiculitis;
• demyelinating diseases;
• nerve damage due to vasculitis and diseases connective tissue;
• compression of nerves (“tunnel syndromes”);
• nerve injuries;
• poisoning with alcohol and other substances.

Peripheral paresis is also called flaccid. Muscle weakness, decreased tone, and weakened reflexes occur. Involuntary muscle twitching is noted. Over time, the muscles decrease in volume (atrophy develops), and contractures occur.

Diagnosis of paresis

Paresis and paralysis are identified by a neurologist during an examination. The doctor asks the patient to make various movements, then tries to flex or straighten the affected limb and asks the patient to resist. A test is performed during which the patient must hold both legs or arms suspended. If muscle strength is reduced in one of the limbs, then after 20 seconds it will noticeably drop down.

After the examination, the doctor prescribes an examination that helps to identify the cause of the paresis.

Treatment and rehabilitation for paresis

Treatment depends on the cause of the paresis. Great importance rehabilitation treatment is provided to restore movements and prevent contractures. Unfortunately, today in many Russian clinics little attention is paid to this issue due to the lack of special equipment and trained specialists.

Rehabilitation treatment for paresis includes:

• therapeutic exercises;
• massage;
• mechanotherapy on special simulators;
• use of orthoses;
• neuromuscular stimulation;
• physiotherapy.

At the Yusupov Hospital, rehabilitation of neurological patients is given increased attention. After all, the restoration of function, performance, and quality of life of the patient in the future depends on this.

Advantages of Yusupov Hospital

• The average experience of our neurologists is 14 years. Many have an academic degree and are doctors highest category;
• Well-developed area of ​​rehabilitation treatment - modern equipment for mechanotherapy, experienced instructors;
• We adhere exclusively to the principles of evidence-based medicine and use the best practices of foreign colleagues;
• We did everything to make the patient feel comfortable in the clinic, to create a positive attitude towards recovery.

All this serves one goal - to achieve maximum therapeutic effect for each patient, the fastest and most complete restoration of impaired functions, improving the quality of life.

Bibliography

• ICD-10 ( International classification diseases)
• Yusupov Hospital
• Batueva E.A., Kaygorodova N.B., Karakulova Yu.V. The influence of neurotrophic therapy on neuropathic pain and the psycho-vegetative status of patients with diabetic neuropathy // Russian Journal of Pain. 2011. No. 2. P. 46.
• Boyko A.N., Batysheva T.T., Kostenko E.V., Pivovarchik E.M., Ganzhula P.A., Ismailov A.M., Lisinker L.N., Khozova A.A., Otcheskaya O .V., Kamchatnov P.R. Neurodiclovit: possibility of use in patients with back pain // Farmateka. 2010. No. 7. pp. 63–68.
• Morozova O.G. Polyneuropathy in somatic practice // Internal medicine. 2007. No. 4 (4). pp. 37–39.

Central paralysis is a pathological condition in which there is complete loss and lack of muscle strength in a particular part of the body. Central paralysis is also known as spastic paralysis, as the pathology is accompanied by muscle hypertension. The most common type of paralysis is central, affecting the arms or legs.

The distinctive characteristics of central paralysis are increased tendon reflexes and muscle tone, and in addition, the appearance of abnormal synkinesis. It is worth noting that it is fundamentally different from damage to the nervous system of the central type, so these conditions are distinguished quite simply. As a rule, when peripheral paralysis There is not only a decrease in muscle strength and the inability to regulate motor activity, but also muscle atrophy, loss of tone, decreased or complete loss of reflexes.

What is central paralysis?

Central type paralysis develops due to damage to the pyramidal system. Depending on the level of damage to the pyramidal system, different signs of central paralysis may be observed. In the event of a number of unfavorable external or internal environment in the area of ​​the anterior central part of the cortex, loss of function of the leg or arm may be observed, and on the opposite side from the focus of the pathological process in the brain.

Pyramidal fibers run in the pons, medulla oblongata, and cerebral peduncles, so damage to these areas can cause a variety of symptoms. As a rule, central paralysis is diffuse in nature, that is, it is accompanied by the spread of symptoms of the lesion to a separate limb or half of the body.

The existing lesion of the pyramidal apparatus leads to the elimination of the influence of the cerebral cortex on the segmental reflex apparatus of the spinal cord. In addition, the pyramidal system’s own reflex apparatus is disinhibited. Against the background of these processes, the excitability and influence of the peripheral segmental apparatus increase. The signs and symptoms associated with central palsy are caused by higher level excitability of the peripheral apparatus, which is largely a means of compensating for the lost connection between the brain and muscles.

The main reasons for the development of central paralysis

First of all, it should be noted that it is necessary to distinguish between phenomena such as. Paresis is a condition in which muscle strength and reflexes are significantly weakened, but are preserved to a certain extent. With paralysis, a person loses the ability to control certain parts of the body. These 2 conditions have something in common, that is, etiology. The reasons for their appearance are rooted in various types of damage to the human nervous system. As a rule, the development of central paralysis is associated with damage to the motor centers or the central pathways of their departments. Such damage to the human nervous system can be caused by:

• injuries;
• infectious lesion;
• metabolic disorders of various etiologies;
• hereditary predisposition;
• congenital malformations;
• intoxication;
• malignant neoplasms;
• unbalanced diet.

Central paralysis occurs predominantly in people over 45 years of age, but currently there is a trend toward “rejuvenation” of this pathological condition. Statistically, more than 60% of cases of central paralysis are the result of a previous stroke.

Job instability circulatory system brain can provoke neuronal damage not only due to hemorrhages, but also when a blood clot forms and blocks blood flow to a certain part of the motor center or pathways. Children, as a rule, have hereditary spastic paraplegia, which manifests itself at an early age.

Symptoms of central paralysis

There are many characteristic signs that distinguish central paralysis from other disorders of the motor function of individual muscle groups associated with damage to the brain or spinal cord. To the most characteristic features central palsy include:

• muscle hypertension;
• expansion of the distribution area of ​​reflexes;
• hyperreflexia;
• clonus of the kneecaps or feet.

Muscular hypertension is a phenomenon characterized by pathological muscle tension. With this pathology, the muscles upon palpation have dense consistency. In addition, a distinctive feature of this condition is increased muscle resistance both during passive movement and under directed influence. In the presence of severe muscle hypertension, the appearance of contractures is observed, which leads to a significant or complete limitation of possible passive and active movements. When contracture occurs, the limb usually freezes in an unnatural position.

Hyperreflexia, accompanied by an increase in the area of ​​influence of reflexes, can provoke many visible manifestations of central paralysis. Clonus of the kneecaps and feet are characterized by the appearance of rhythmic contractile movements of individual muscles as a reaction to tendon stretching. As a rule, clonus is a consequence of a significant increase in tendon reflexes. Typically, foot clonus is a consequence of rapid dorsiflexion. In response to such an impact, a reflex rhythmic twitching of the foot is observed. Patella clonus usually develops as a result of a sharp abduction of the leg downwards.

The appearance of pathological reflexes is an indicative sign of damage to any level of the pyramidal tract. Pathological reflexes of the hand and foot can be distinguished. The most indicative pathological reflex movements include the reflexes of Zhukovsky, Babinsky, Gordon, Rossolimo, Oppenheim and Schaeffer.

Among other things, protective reflexes are indicative, which provoke twitching of a paralyzed limb in response to mechanical or thermal influence.

Another characteristic sign of the development of central paralysis is synkinesis. Synkinesis is involuntary cooperative movements in the damaged limb against the background of active directed actions. An example of synkinesis is the swinging of arms while walking, bending or straightening of arms or legs when performing active movements on the half of the body that is not subject to central paralysis. There are many types of synkinesis that may indicate spastic paralysis.

Muscle spasticity, which is a consequence of increased reflex tone, is often unevenly distributed. In most cases, with central paralysis, half the body is affected at once, and the arm in this case, as a rule, is close to the body, the hand and all fingers are bent, while the leg is fully extended at both the hip and knee joints, and the foot is bent and turned inward. This position of the limbs is a very common manifestation of central hemiplegia. The characteristic posture resulting from this arrangement of the limbs in central palsy is known as the Wernicke-Mann manifestation. Gait in people with similar manifestation central paralysis is very peculiar, since in order not to cling to the floor with the toe of the affected leg, the patient is forced to move it far away. Central facial paralysis is usually accompanied by numbness of the tongue and palate, facial tics, involuntary eye movements, etc.

Despite a significant increase in tendon reflexes, with central paralysis there is a significant decrease or complete loss of abdominal, cremasteric and plantar reflexes. Among other things, central paralysis is characterized by the absence of pronounced muscle atrophy. The most noticeable manifestations of central paralysis include:

• unnatural posture of the patient;
• low or increased mobility;
• paresis of facial muscles;
• phonation disturbances during speech;
• speech disorders;
• convulsive muscle twitching;
• muscle tremors;
• incorrect gait;
• upward wrinkling of muscles;
• involuntary opening of the mouth;
• closing of eyelids;
• involuntary shrugging of shoulders;
• involuntary flexion and extension of the hands, elbows and other joints;
• increased muscle tone when palpated.

All the symptoms accompanying spastic paralysis make it possible not only to distinguish it from the peripheral form of motor impairment, but also to identify the main area of ​​damage to the pyramidal tract.

Diagnosis and treatment of central palsy

As a rule, the diagnosis of central paralysis is made after consultation with a neurologist. The doctor collects anamnesis and palpates the limbs affected by paralysis, and also invites the patient to undergo several simple but diagnostic tests. meaningful tests, which allow us to assess the degree and characteristics of paralysis of the limbs.

Paralysis, regardless of its type, is not an independent disease, therefore for effective fight should be dealt with first drug treatment root causes of neuronal damage.

Treatment of paralysis is symptomatic. Physiotherapy plays the main role in the treatment of paralysis, since it is often no longer possible to restore damaged brain structures.

With the correct selection of a gymnastics complex and other means of physiotherapy, you can improve general state sick.

Massage at spastic paralysis is also an important part of rehabilitation.

Physiotherapy can significantly improve the quality of life of patients, and in addition, prevent the development of contractures and deformities.

Paresis does not have one clear cause. It can occur with any type of damage to the brain, spinal cord, or peripheral nerves. Depending on the level of damage, there are central(at the level of the brain and spinal cord) and peripheral (at the level of peripheral nerves) paresis.

Central paresis

Central paresis occurs when the brain or spinal cord is damaged. Disorders develop below the site of injury and usually affect the right or left half of the body (this condition is called hemiparesis). Most often, this picture can be observed in a patient who has suffered a stroke.

Sometimes central paresis causes problems in both arms or both legs ( paraparesis), and in the most severe cases - in all 4 limbs ( tetraparesis).

The main causes of central paresis:

• stroke;
• traumatic brain injuries, spinal cord injuries;
• encephalitis;
• tumors of the brain and spinal cord;
• osteochondrosis, intervertebral hernia;
• cerebral circulatory insufficiency due to atherosclerosis, arterial hypertension or other causes;
• multiple sclerosis;
• amyotrophic lateral sclerosis;
• cerebral palsy (CP).

With central paresis, the decrease in muscle strength is expressed to varying degrees. In some cases it manifests itself in the form of rapid fatigue and awkwardness, while in others there is an almost complete loss of movement.

With central paresis, the part of the spinal cord below the site of injury remains intact - it tries to compensate for the disturbance. This leads to an increase in the tone of the affected muscles, strengthening of normal reflexes and the appearance of new, pathological ones, which do not occur in a healthy person. Thus, in a patient who has suffered a stroke, the tone of the forearm flexor muscles increases. Therefore, the arm is always bent at the elbow. On the leg, on the contrary, the tone of the extensors increases - due to this, it bends at the knee worse. Neurologists even have a figurative expression: “the hand asks, but the foot mows.”

Due to increased muscle tone and impaired movement, central paresis can lead to contractures (restriction of movement in the joints).

Peripheral paresis

Peripheral paresis occurs when the nerve is directly damaged. In this case, disorders develop in one group of muscles that this nerve innervates. For example, muscle weakness may be present in only one arm or leg (monoparesis). The larger the nerve is damaged, the larger part of the body the paresis covers.

The main causes of peripheral paresis:

• degenerative diseases of the spine, radiculitis;
• demyelinating diseases;
• nerve damage due to vasculitis and connective tissue diseases;
• compression of nerves (“tunnel syndromes”);
• nerve injuries;
• poisoning with alcohol and other substances.

Peripheral paresis is also called flaccid. Muscle weakness, decreased tone, and weakened reflexes occur. Involuntary muscle twitching is noted. Over time, the muscles decrease in volume (atrophy develops), and contractures occur.

Diagnosis of paresis

Paresis and paralysis are identified by a neurologist during an examination. The doctor asks the patient to make various movements, then tries to flex or straighten the affected limb and asks the patient to resist. A test is performed during which the patient must hold both legs or arms suspended. If muscle strength is reduced in one of the limbs, then after 20 seconds it will noticeably drop down.

After the examination, the doctor prescribes an examination that helps to identify the cause of the paresis.

Treatment and rehabilitation for paresis

Treatment depends on the cause of the paresis. Rehabilitation treatment is of great importance for restoring movements and preventing contractures. Unfortunately, today in many Russian clinics little attention is paid to this issue due to the lack of special equipment and trained specialists.

Rehabilitation treatment for paresis includes:

• therapeutic exercises;
• massage;
• mechanotherapy on special simulators;
• use of orthoses;
• neuromuscular stimulation;
• physiotherapy.

At the Yusupov Hospital, increased attention is paid to the rehabilitation of neurological patients. After all, the restoration of function, performance, and quality of life of the patient in the future depends on this.

Advantages of Yusupov Hospital

• The average experience of our neurologists is 14 years. Many have an academic degree and are doctors of the highest category;
• Well-developed area of ​​rehabilitation treatment - modern equipment for mechanotherapy, experienced instructors;
• We adhere exclusively to the principles of evidence-based medicine and use the best practices of foreign colleagues;
• We did everything to make the patient feel comfortable in the clinic, to create a positive attitude towards recovery.

All this serves one goal - to achieve the maximum therapeutic effect in each patient, the fastest and most complete restoration of impaired functions, and improve the quality of life.

/ Central paresis

Topic: Voluntary movements and their disorder. Anatomy and physiology of voluntary movements. Phenomenology of peripheral paresis syndrome with different localization of lesions. Rehabilitation of patients with central paresis

Voluntary movements form the basis of human life. They arise as a result of the close interaction of motor (efferent) and sensory (afferent) systems. Voluntary movements are provided by many motor systems, among which one of the main places is occupied by corticomuscular tract.

The corticomuscular tract includes the central motor neuron (motor neuron), peripheral motor neuron, and muscle.

Central(upper) motor neurons are located primarily in the precentral gyrus (posterior parts of the frontal lobe). Betz's giant pyramidal cells are located in the primary motor cortex; fast-conducting axons from them make up 3-5% of all fibers of the pyramidal tract. Along with Betz giant cells, the primary motor cortex contains small pyramidal cells, the axons of which form about 40% of all fibers of the pyramidal tract. IN upper section the precentral gyrus and the paracentral lobule contain neurons that innervate the lower limb and trunk; in the middle section there are neurons that innervate the upper limb; in the lower section - neurons innervating the muscles of the face, pharynx, and larynx. This projection to a certain extent corresponds to a person standing on his head.

Peripheral(lower) motor neurons are located in the motor nuclei cranial nerves and in the anterior horns of the spinal cord. The axons of the cells of the anterior horns of the spinal cord form the anterior roots, which, connecting with the dorsal root, form the spinal nerves. From the spinal nerves, plexuses are first formed, then peripheral nerves. Peripheral motor neurons innervating the neck muscles are located in the upper cervical segments (C 1 -C 4), motor neurons innervating the upper limbs are in the cervical thickening (C 5 -Th 2 segments of the spinal cord); motor neurons innervating the lower limbs - in the lumbar enlargement (Th 12 -S 2 segments of the spinal cord); motor neurons innervating the trunk muscles are in the thoracic spinal cord.

In providing voluntary movements important role reflexes play. Unconditioned reflexes are closed in the segmental apparatus of the spinal cord and brain stem. A two-neuron reflex arc consists of a receptor, a sensory neuron, a motor neuron, and a muscle. The three-neuron reflex arc additionally includes an interneuron between the sensory neuron and the motor neuron.

Methodology clinical trial voluntary movements. Study motor system includes an external examination of the musculoskeletal system, assessment of the volume, strength and tempo of voluntary movements, study of muscle tone and deep (tendon and periosteal) and superficial (skin) reflexes, and study of gait. At external inspection You can detect muscle atrophy and fasciculations - spontaneous non-rhythmic contractions of muscle bundles. Of particular importance is the identification of local (local) muscle atrophy. When studying active movements in the limbs of the body, their volume is first determined, then their strength. If movements are limited in volume in any joint, passive movements are examined in it, during which osteoarticular changes can be identified, for example, arthrosis, which explains the limitation of movements. In these cases, the limitation of movements is not caused by pathology of the corticomuscular pathway. To test muscle strength, the examinee is asked to perform a movement that involves that muscle and hold that position while the examiner attempts to perform a movement in the opposite direction. For example, to study the strength of the biceps brachii muscle, the subject is asked to bend his arm in a elbow joint and try to keep your arm in this position while the doctor tries to straighten it. To quantify muscle strength, additional devices can be used, such as a dynamometer to assess hand muscle strength. When assessing the results of a study, it is necessary to take into account physical development the subject, his age and gender. It is advisable to compare muscle strength on both sides, taking into account that in right-handed people, the strength in the right limbs, as a rule, is slightly greater than in the left, and in left-handed people, on the contrary, the strength is greater in the left limbs.

To identify hidden limb paresis, you can use Bare sample. To identify paresis in the upper extremities, the examinee is asked to raise them, close their eyes and hold the upper extremities in this position for several seconds. To detect paresis in the lower extremities, the examinee is asked to lie on his stomach, close his eyes, bend his lower extremities at the knee joints and hold them in this position for several seconds. If there is paresis in one of the limbs, then it may lower or deviate from a given position in comparison with the healthy side. Muscle tone is assessed by the resistance that occurs in a relaxed muscle in response to its passive stretching (passive movements of the patient's limbs); the study is carried out in all joints of the upper and lower extremities. For example, when bending the elbow joint, a passive stretch of the triceps brachii muscle and its reflex tension occurs; when extending the elbow joint, a passive stretch of the biceps brachii muscle and its reflex tension occurs. Normally, a slight tension in the muscle is felt in response to its passive stretching. With an increase in muscle tone, significant muscle tension is noted, with muscle hypotension

The study of reflexes is of great importance. On the upper extremities, reflexes from the biceps brachii tendon (biceps reflex), from the triceps brachii tendon (triceps reflex) and the carporadial reflex (carpal radial reflex) are examined, on the lower extremities - knee and Achilles reflexes. Tendon and periosteal reflexes are examined using a neurological hammer. Hammer blows should be applied lightly and infrequently, with equal force when comparing reflexes on the right and left sides. When a hammer hits a muscle tendon, not only irritation of the tendon receptors occurs, but also stretching of the muscle, which leads to excitation of the receptors located in the muscle and the occurrence of a reflex, therefore, from a physiological point of view, the tendon reflex is more correctly regarded as a reflex to stretch the muscle (myotatic reflex). In addition to tendon and periosteal reflexes, deep and superficial abdominal reflexes, plantar reflex, anal and cremasteric reflexes are also examined. When studying reflexes, pay attention to their symmetry and liveliness. Therefore, it is better to examine each reflex immediately from the right and left sides, comparing their vivacity. Each reflex is assessed according to the degree of vividness: normal, increased (hyperreflexia), decreased (hyporeflexia), absent or lost (areflexia). Reflexes have significant individual variability, but normally they are the same in vividness on the left and right sides.

Symptoms of central and peripheral paresis

Central paresis (spastic paresis) is a paresis that occurs when the upper (cortical) motor neuron and/or the main motor pathway (syn. corticospinal and corticobulbar tract, pyramidal tract) are damaged at the level of the brain or spinal cord. In clinical practice, hemiparesis is most common with lesions in the brain, and lower paraparesis with lesions of the spinal cord. The causes of the development of central paresis (CP) are:

Acute diseases and brain damage (stroke, trauma, encephalitis);

Acute diseases and injuries of the spinal cord (trauma, spinal stroke, acute myelitis);

Tumors (and other space-occupying diseases) of the brain and spinal cord;

Progressive diseases of the central nervous system of vascular origin (dyscirculatory encephalopathies, myelopathies), autoimmune (multiple sclerosis), hereditary (Strumpell's disease), amyotrophic lateral sclerosis, diseases of other, often unclear origins;

Cerebral palsy (pre-, peri- and postnatal encephalopathy).

Paresis- a disorder of voluntary movements in the form of a decrease in strength and range of movements, it is caused by damage to the cortico-muscular pathway.

Plegia, or paralysis, − complete absence movements. Paresis or paralysis of the limbs with damage to the cortico-muscular tract in any area: brain, spinal cord, anterior roots, plexuses, nerves, neuromuscular junction and muscle. Paresis does not include limitation of movements due to pain due to damage to the osseous-ligamentous apparatus. The degree of paresis can be assessed quantitatively, for example, using a 5-point system: 5 points - movements in full force (no paresis); 4 points – slight decrease in strength; 3 points – moderate decrease in strength, but full range of motion even under the influence of gravity; 2 points - significant decrease in strength, full range of movements is possible only when gravity does not act on the limb (for example, in a lying position the patient cannot raise the leg, but in the horizontal plane bends the leg in hip joint in full); 1 point − minimal movement or only visible muscle contraction without movement of the limb; 0 points – lack of movement (plegia, or paralysis). Paresis of 4 points is regarded as mild, 3 points as moderate, 1 and 2 points as deep.

Paresis (plegia) of one limb is defined as monoparesis (monoplegia), paresis in the named limbs − hemiparesis (hemiplegia), paresis in the upper and lower extremities - respectively upper and lower paraparesis (paraplegia), paresis in three limbs − triparesis (triplegia), paresis in all limbs − tetraparesis (tetraplegia).

There are two types of paresis - central and peripheral, which differ in their clinical signs and occur, respectively, when the central or peripheral motor neuron is damaged.

Central paresis (spastic paresis) develops when the pyramidal (corticospinal) tract in the brain or spinal cord is damaged. With central paresis in the limb, as a rule, muscle tone increases, tendon and periosteal reflexes are revived, and pathological reflexes appear (Babinsky, Rossimo, Hoffmann, etc.). With central paresis, muscle tone often increases by type of spasticity− the degree of increase in muscle tension depends on the speed of passive movement, the “jackknife” phenomenon is observed (maximum resistance to passive movement at the beginning of the study), the tone is increased to the maximum in the flexors of the upper limb and extensors of the lower limb, adductor muscles of the shoulder and thigh. The revitalization of reflexes is often accompanied by an expansion of their reflexogenic zone.

Causes of paresis. Among central paresis of the limbs, the most common is hemiparesis, which, when acute development more often caused by a stroke, and if gradual - by a brain tumor. Central monoparesis of an arm or leg is much less common and is usually caused by stroke, traumatic brain injury, multiple sclerosis or a tumor of the brain or spinal cord. Central paresis of both legs (lower paraparesis) is most often caused by multiple sclerosis, a tumor or other disease of the spinal cord, less often by bilateral damage to the cerebral hemispheres due to perinatal damage (cerebral palsy), traumatic brain injury or tumor.

Superficial reflexes (abdominal, cremasteric, anal, plantar) can be reduced or even lost with central limb paresis. Muscle wasting with central paresis may not be observed, however, if paresis persists for a long time (months, years), it is usually noted, although it is less pronounced than with peripheral paresis of the limb. May be observed defensive reflexes− involuntary movements in paretic limbs that occur in response to intense irritation of skin receptors or deeper tissues, for example, the application of painful irritation to the skin in the form of an injection. When moving in paretic limbs, there may be pathological synkinesis(friendly movements), for example, raising the arm in the shoulder joint when trying to squeeze the hand or when sneezing, laughing, yawning.

With central paresis of the limbs, disturbances in posture and gait may occur. With central hemiparesis, the Wernicke-Mann position is observed: the upper limb is bent at the elbow and wrist joints, brought to the body, the lower limb is carried forward when walking, describing a circle.

IN acute period some neurological diseases(cerebral stroke, spinal cord injury), muscle hypotonia and hyporeflexia may develop due to decreased excitability of the segmental apparatus of the spinal cord (stage of “spinal shock”). However, in the future, characteristic signs of central paresis are usually observed - muscle hypertension of the type of spasticity and hyperreflexia.

Rehabilitation of patients with central paresis

The main methods of motor rehabilitation of patients with spastic paresis include:

Training using biofeedback;

Complexes of therapeutic exercises for patients with spastic paresis include both physical exercises aimed at general training of the body and special exercises, acting directly on the affected area and promoting the restoration of functions impaired due to the disease. A set of physical exercises for special training for spastic paresis consists of a set of exercises aimed at:

Strengthening muscle strength and increasing range of motion in joints;

Reduction and normalization of increased muscle tone;

Elimination of pathological friendly movements;

Improving coordination capabilities;

Balance function training;

Reducing sensitivity disorders;

Teaching the most important motor skills (standing, walking, household self-care skills).

These are primarily exercises in an isometric mode, which ensures contraction of the muscle without shortening it, i.e. without movement in the joints. As a rule, these exercises are used in patients who have no or minimal voluntary muscle activity. When performing exercises in this mode, it is necessary, firstly, to ensure a certain position of the limb or part of the body, the muscles are trained, and, secondly, to use special support from the LH instructor. So, in order to achieve isometric contraction of the extensors of the hands and fingers, the patient is placed on his back, the arm is bent at the elbow joint and the forearm is placed in a vertical position. Then you should straighten (straighten the hand and fingers so that they form 180° with the forearm). Holding the paretic arm by the forearm, the patient is asked to hold the hand and fingers in this extended position. In the same starting position, but holding the paretic arm by the hand, the patient is asked to hold the forearm in the given position. vertical position. This exercise is aimed at training the forearm flexors in an isometric manner. To train the forearm extensors, the patient’s paretic arm is extended at the elbow joint and raised vertically upward, fixing the patient’s shoulder; he is asked to hold his arm in a raised position. To do this, he must tense the extensors of the forearm. Isometric contraction of the abductor muscles of the shoulder is carried out with the patient positioned on the healthy side. The paretic arm is raised up and bent at the elbow joint at an angle of 90°. While supporting the forearm, ask the patient to hold his hand in this position. The hip flexors are trained isometrically with the patient in the supine position. The paretic leg is bent at the knee joint, lightly holding it by the shin. The patient is asked to hold the leg in this position, preventing it from straightening at the knee joint. In the same starting position, you can train the hip abductors. Slightly moving the leg bent at the knee joint to the side, the patient is asked to hold it in a fixed position. These exercises make up the initial complex of active gymnastics. In the first days of classes, they should be performed 2-3 times, gradually increasing the number of exercises to 5-10. When independent isolated movements appear in patients, they begin to train the latter using so-called lightweight exercises aimed at eliminating the undesirable influence of gravity. It is best to carry them out using various suspensions, hammocks and blocks. Light exercise should not cause pain. They are performed at a slow pace, in a volume accessible to the patient. First of all, exercises are carried out for muscles whose tone usually does not increase. So, for example, supporting a paretic arm with a hammock or placing it on a ball, the patient is asked to perform those active movements that he has already developed. This is abduction and adduction of the shoulder, flexion and extension of the forearm, extension of the hand.

Easier abduction and adduction of the hip is trained with the patient in the supine position; turning the patient onto the healthy side and supporting the affected leg, train the extension and flexion of the lower leg; when the range of active movements increases over time, exercises with light dosed resistance should be added. This is done like this: for example, when actively extending the lower leg, you should try to slightly impede this movement by pressing on top of the lower leg and preventing the leg from extending at the knee joint. Exercises with light resistance are carried out similarly for the remaining muscle groups. It must be remembered that resistance exercises are included in the complex of active gymnastics only when active isolated movements appear in a sufficiently large volume. While performing these exercises, the patient should not hold his breath. Resistance exercises must be combined with passive exercises for relaxation. To suppress pathological synkinesis, such as flexion of the arm at the elbow joint while simultaneously flexing the thigh and leg, various techniques are used depending on the severity of the paresis:

1) conscious suppression of synkinesis (with mild paresis);

2) orthopedic fixation (using splints, elastic bandage, orthopedic shoes, special orthoses) of one or two joints in which synkinesis is most pronounced; 3) special anti-friendly passive and active-passive exercises performed with the help of a methodologist and consisting in breaking down the usual synergistic stereotype.

A set of such exercises is known, aimed at combating synkinesis, for example, to suppress synkinesis in a paretic arm during passive or active movement in a paretic leg. An example is the following exercise: the patient sits at a table with his feet shoulder-width apart. The arms are extended at the elbows and lie on the table, the hand of the healthy hand fixes the hand of the paretic hand. The patient begins to slowly bend and straighten his leg at the knee joint (if this is difficult to do, then you should help the sore leg with the help of the healthy one), while simultaneously holding the paretic arm in an extended position with your healthy hand. You can also, while sitting on a chair, stretch your arms forward (paretic below, healthy above) and place them on a cane, which is located on the side of the sore leg. It is necessary to keep your arms extended during the next movement of your legs: put the sore leg on the healthy knee, return to the starting position, put the healthy leg on the sick knee, return to the starting position. Of great interest is the use of robotic devices to overcome pathological muscle synergies that arise when a patient with severe spastic paresis attempts to make any voluntary movement.

The robotic orthosis, fixed on the patient’s paretic arm, is programmed in such a way that it prevents the appearance of flexion synergy in the arm during voluntary movements. Train with this robotic orthosis for 8 weeks. (3 times a week) leads to a significant decrease in the severity of synergy and increases the functionality of the hand. To overcome pathological flexion synkinesis in the elbow joint while teaching the patient motor skills (for example, turning on and off the light), you can use a special orthosis that prevents flexion of the arm at the elbow joint.

Exercises to improve coordination are aimed at increasing the accuracy and precision of movements (movements with sudden stops, changes in speed and direction, training to aim and hit index finger at a stationary or moving target, throwing a ball), exercises with small objects (assembling and disassembling construction sets), etc.

Exercises aimed at training the balance function are given particular importance in the treatment of patients with spastic paresis. According to some researchers, the early inclusion of these exercises in the therapeutic-gymnastic complex in such patients not only helps to train the balance function, stability of the vertical posture, and a more even distribution of weight between the paretic and healthy leg, but, most importantly, prevents the development of severe spasticity. To train balance in a standing position and when walking, use walking in a straight line or along a stencil, sideways, backwards, on an uneven surface, on toes, with eyes closed, exercises with an exercise ball, exercises with pushing by introducing the patient from an equilibrium state into a sitting position , standing) with provided support from the LG instructor.

Exercises aimed at reducing sensitivity disorders include primarily all exercises aimed at improving motor functions(ranging from exercises to train muscle strength to exercises to teach critical motor skills). In addition, special therapeutic and gymnastic techniques are used aimed at improving sensitivity, which include training in dosed muscle efforts and the development of various motor qualities (speed, accuracy, endurance). Restoration of muscle-joint sensation is carried out by strengthening other types of sensitivity, relearning motor skills by ensuring optimal replacement of lost functions. A significant role in these trainings belongs to increasing the patient’s concentration on the sensation of the muscle contraction he performs. In addition, tactile stimulation is widely used (for example, in the form of irritation of the skin of a paretic limb with ice, vibration, pressure), which also helps the patient to understand the position of his affected limb in space. When using these special therapeutic and gymnastic techniques, visual control and informing the patient about the accuracy of his movement are important.

Teaching the most important motor skills occupies an important place in the PH complex in patients with spastic paresis. Currently, numerous studies are being conducted to study the possibility of using so-called forced training in patients who have suffered a stroke.

For patients with mild post-stroke hemiparesis and a disease duration of more than 1 year. The essence of the proposed method is that the healthy arm is fixed using special devices to the body, so that the patient cannot use it. This creates conditions under which the patient's entire attention is fixed on the use of the paretic arm while learning various motor skills.

Walking recovery goes through a number of successive stages: imitation of walking lying down, sitting, standing by the bed, walking with support, walking with support on a chair or on a 3-4-support cane, walking with support on a stick within a room (ward, hospital department, apartment), training in walking up stairs, walking outdoors (in the yard, on the street), using public transport. First, the patient is taught to move from a lying position to a sitting position, then to sit with his legs down. An important point is teaching the patient how to get out of bed or chair correctly. After the patient can confidently, holding onto a support, stand independently on both legs, they move on to teaching him how to alternately transfer the weight of the body to the healthy and sore leg. To do this, the patient is asked to place his feet shoulder-width apart and perform gentle rocking from side to side. It is necessary to support it while performing this exercise. When the patient has mastered this exercise, it is necessary to move on to learning to stand on one leg. When performing this exercise, it is necessary that the patient has reliable support: a high headboard, a bedside frame, a bracket driven into the wall. There should be a chair behind him for safety or rest.

Currently, gait training using treadmills with body weight-supporting systems is considered the most effective technology for restoring gait for patients with post-stroke hemiparesis. As a result of such training, patients' walking speed significantly increases and the biomechanical parameters of their step improve. IN last years the systems under consideration were supplemented with computerized robotic orthoses that provide passive movements in the lower extremities simulating a step. According to experts, such robotic orthoses primarily facilitate the work of exercise therapy instructors.

Learning household skills also goes through certain stages: first, this is learning the simplest skills - independent eating, personal hygiene, then learning how to dress independently, use the toilet and bathroom. Using the bathroom on your own is the most difficult part of regaining self-care. Training is also carried out on how to use a telephone, a TV, a computer if necessary, various household appliances, for example, turning a gas or electric stove on and off, using an electric kettle, a razor, opening a lock with a key, etc. For this purpose, training stands with various household items built into them are widely used.

Therapeutic gymnastics in the pool

According to some authors, hydrotherapy (treatment in a pool) is unique method rehabilitation therapy of patients with central spastic paresis. Immersion of the patient in the pool, leading to a significant decrease in gravity, provides maximum freedom of movement and allows you to practice exercises aimed at muscle stretching, reducing contractures, learning motor patterns, balance and reactions to balance, and walking. LH in the pool is most widely used in patients with consequences of spinal cord injury.

Peripheral and central paresis (paralysis)

2. Paralysis due to damage to corticospinal, corticobulbar or stem descending (subcorticospinal) neurons;

3. Coordination disorders (ataxia) as a result of lesions of the afferent and efferent fibers of the cerebellar system;

4.Disturbances in movement and body position due to damage to the extrapyramidal system;

5.Apraxia or non-paralytic disorders of purposeful movements due to brain damage.

Isolated activity of individual muscle fibers is called fibrillation; fibrillation activity is so small that it cannot be seen through the skin; it is recorded only in the form of a short-term action potential on the EMG.

Although the innervation of muscles corresponds approximately to the segments of the spinal cord, each large muscle is innervated by two or more roots. A single peripheral nerve, in contrast, usually provides motor innervation to one muscle or group of muscles. For this reason, the distribution of paralysis due to lesions of the anterior horns or anterior roots of the spinal cord differs from that due to lesions peripheral nerve.

Peripheral motor neuron palsy is caused by physiological blockade or destruction of anterior horn cells or their axons in the anterior roots and nerves. Objective and subjective symptoms vary depending on the location of the lesion. In clinical practice, the most important thing is to identify sensory disorders. The combination of flaccid paralysis with areflexia and loss of sensitivity usually indicates mixed damage to the motor and sensory nerves or damage to both the anterior and posterior roots. If there are no sensitivity disorders, in pathological process the gray matter of the spinal cord, the ventral roots, the motor branch of the peripheral nerve, or the axons of motor neurons may be involved. Sometimes it can be difficult to distinguish between lesions of the nuclei (spinal) and the anterior roots (radicular).

Denervated muscles atrophy, losing up to 20-30% of their original mass within 4 months. The reflex reaction of the muscle to a sudden stretch, such as a blow to the tendon with a hammer, disappears. If only some of the motor units are affected, partial paralysis develops. In case of incomplete denervation, the presence of fibrillations can also be detected on the EMG.

The lateral stem pathways (coming from the magnocellular part of the red nucleus and the ventrolateral parts of the tegmentum of the pons) end on interneurons related primarily to the muscles of the arms.

The ventromedial pathways of the brain stem (from the superior colliculus, intermediate nucleus of Cajal, medial parts of the reticular formation of the pons, medulla oblongata and midbrain, as well as from the vestibular nuclei) end on interneurons associated with the muscles of the trunk, pelvic and shoulder girdles

With isolated unilateral destruction of the medulla oblongata pyramid, a significant degree of restoration of motor functions is noted in the upper or lower limb of the side opposite to the lesion, only some spasticity remains, an increase in tendon reflexes and a muscle stretch reflex, as well as an extensor plantar reflex (Babyansky's symptom). This restoration of function is due to the preservation of some fibers in the pyramid, as well as the lateral stem pathways.

Acute lesions of the lower parts of the corticospinal and subcorticospinal motor pathways, for example at the level of the spinal cord, can lead not only to the development of motor paralysis, but also to a temporary inhibition of spinal reflexes provided by segments located below the level of the lesion. This condition is called spinal shock. Under favorable conditions, after a few days or weeks the shock passes, and a peculiar condition called spasticity occurs.

Spasticity is a characteristic feature of all lesions of the motor pathways at the level cerebral hemispheres brain, internal capsule, midbrain, pons.

With cerebral and brainstem lesions, spasticity does not occur immediately after the lesion; in some cases, the paralyzed limbs remain flaccid, but tendon reflexes are present. Spasticity is associated with excessive activity of spinal motor neurons released from inhibitory influences and is one of the components of central motor neuron lesion syndrome. The peculiar position of the limbs indicates that some spinal neurons are in a more active state than others. When the lesion is located above the spinal cord, the arm is slightly bent and pronated, the leg is extended and extended. Any attempts to straighten an arm or bend a leg are met with resistance after a short period of time, which increases, and then can sharply weaken (jackknife phenomenon). If you change the position of the limb, resistance arises again (lengthening and shortening reactions). However, jackknife spasticity is uncommon. For combined lesions of the corticospinal and other suprasegmental pathways, the appearance of continuous resistance to passive movements is more typical. Protective spinal flexion reflexes, which include Babinski's symptom, are also disinhibited, and the musculocutaneous abdominal and cremasteric reflexes are inhibited. In case of brain damage, increased skin reflexes and muscle stretch reflexes can be observed in the muscles of the head, limbs and trunk; with bilateral damage to the corticospinal tract develops pseudobulbar palsy(dysarthria, dysphonia, dysphagia, bilateral facial paralysis), usually accompanied by “emotional lability.”

With lesions of the spinal cord, prolonged convulsions develop in the flexors and extensors; they arise due to disinhibition of skin reflexes. Preservation of reflexes and spasticity in paretic muscles resulting from spinal lesions indicate damage to the descending motor pathways and the integrity of the segments located below the level of the lesion.

What is limb paresis and how to treat it with homeopathy

Paresis is a neurological syndrome accompanied by a decrease in muscle strength and a decrease in the ability to make targeted active movements due to damage to the nervous system.

Most often, paresis develops in the upper and lower extremities. Less common is paresis in the area of ​​innervation of the facial, glossopharyngeal and hypoglossal nerves.

Photo 1. Most often, paresis affects the arms or legs.